In part one, we discussed the evolution of spinal immobilization protocols used by most EMS systems and the increasing evidence that shows they often do more harm than good. In this part, I’ll cover options for developing a more appropriate approach.
First, let’s examine the equipment used for spinal immobilization and what we now know about their use.
Evidence on collars
The current generation of collars appears to be insufficient for immobilizing an unstable spine.1 Collars do not restrict motion enough to effectively splint the spine as previously thought.
In addition, one cadaver study found that our current generation of rigid collars tends to distract, or pull, the spine apart.2 Collars also have some unintended consequences, such as the creation of two pivot points: One at the cranio-cervical junction and another at C-5 and C-6.
In other words, it appears that if a patient has a stable injury, the only likely effect of the collar is to cause discomfort and possibly pain. On the other hand, the evidence suggests that if an unstable injury is present, the collar may focus direct force and distraction on the injury site.
One “proof of principle” study, published in 2012, researched the effectiveness of head blocks versus a collar, and concluded that once a patient is laying supine, only the head blocks have any function in preventing flexion, extension and lateral movement.3 The collar has little value by itself and no value once immobilized by a head block device.
In summary, this generation of rigid collars may harm an unstable spine, does not immobilize the neck sufficiently, may increase intracranial pressure and causes pain to the patient. Only head blocks limit range of motion by almost 100%.
It would appear that the only use for collars may be to limit cervical movement during self-extrication or rescuer-assisted extrication from a vehicle.
Evidence on backboards
The spine board, or backboard, was originally used as an extrication tool because its slick surface facilitated movement. It was never intended to hold a patient for an extended period of time. Since its use as a spinal immobilization device, a number of papers have been published that describe the adverse effect of laying supine on a hard surface over time.4 No surprise here! All 100% of the subjects studied developed pain from laying supine on a spine board. Further, 29% developed additional symptoms over the next 48 hours. EMTs have long quipped that if a patient didn’t have pain before we immobilized them, they would afterward.
Another paper documented that immobilization complicates the physical exam by causing vertebral tenderness. The result is a patient with positive findings who requires spinal imaging, unnecessarily adding to healthcare costs.5
Both common sense and medical evidence dictate that supine patients should have padding placed between their posterior and the spine board. In short, increased padding increases comfort and decreases ischemic pain when laying on a hard surface.6
Many elderly “fall” patients cannot have their spine cleared and must have spinal motion restriction based on exam findings. For many of these patients an unpadded spine board is a form of cruel and unusual punishment, due to a kyphotic spine forced to lay on a hard surface.
Most EMTs were taught to always pad a splint, but padding of a spine board is rarely performed by prehospital personnel. The evidence is compelling and is common sense: Unpadded backboards not only cause pain, they are harmful. The first principle of medicine is to “do no harm.” Some rationalize that short transport times make padding unnecessary. However, they fail to appreciate that some patients must lay on a board for an extended period of time once they arrive at the hospital.
Alternatives to backboards
Vacuum Mattress: One device that has been used in Europe for decades is the vacuum mattress. In several studies it has consistently shown to be highly effective at spinal motion restriction, as well as being comfortable for the patient.7 In addition to full mattress configuration, at least one manufacturer has developed vacuum pads to be used as padding on long backboards, increasing comfort time and immobilization effectiveness.
The vacuum technology can also eliminate head blocks because the mattress or pad can be wrapped next to the head, preventing flexion, extension and lateral movement. In Hauswald’s paper, this technology is emphasized as being superior because it provides greater motion restriction, is comfortable, and causes minimal harm.6
Short Spinal Immobilization: In comparing extrication methods, three studies have arrived at the same conclusion: Applying a collar and allowing a patient to self-extricate (if they are capable of doing so) causes the least movement to the spine. This was compared to conventional “rapid extrication to a spine board or short spinal device to a spine board.8,9 It would seem that the only use for a “non-distracting” collar would be for “self-extrication” and the only use for a short spinal device is to place “handles on the patient” for a difficult extrication.
So, absent other findings, a collar and self-extrication may be the safest option for patient in need of spinal motion restriction.
Tips for minimizing risk
EMS leaders, educators and physicians need to take a hard look at the evidence and start looking at what can be done today to “do no harm.” It is unlikely in our country that we would abandon immobilization. However, there are a number of evidence-based alternatives to minimize risk to our patients:
1. Implement selective spinal immobilization protocols. Provide training and conduct intensive quality improvement regarding when to and not to immobilize. This is not new information and it is evidence-based medicine that must be “operationalized.”
2. De-emphasize the use of rigid collars. The evidence is compelling. They not only are incredibly uncomfortable, they may cause significant harm. They do a poor job of immobilization and allow for considerable range of motion. The evidence shows that only the head restraint blocks limit range of motion effectively. Based on the evidence, perhaps the only use for a collar is for extrication and moving a patient to a supine position.
3. If backboards are used, they must be padded. Evidence and common sense require that no patient be placed on an unpadded board. It causes pain and pressure sores, complicates the exam and causes symptoms as long as 48 hours after removal. If the FDA regulated this device, it would be pulled from the market or have a “black box” warning. Use padding–not excuses.
4. Move toward vacuum mattress technology. It provides superior immobilization and comfort for patients.
5. Develop operational protocols that allow patients with isolated neck pain to perform controlled self-extrication.
Although there’s little evidence to support our current practices of immobilization, it’s unlikely we can abandon immobilization entirely. Perhaps the best approach is the one outlined by Hauswald in his piece on “re-conceptualization” of spinal immobilization: We need to restrict the motion of the spine and we also need to do no harm.
References
1. Horodyski M, DiPaola CP, Conrad BP, Rechtine GR 2nd. Collars are insufficient for immobilizing an unstable cervical spine injury. J Emerg Med. 2011 Nov;41(5):513—9.
2. Ben-Galim P, Dreiangel N, Mattox KL, et al. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010;69(2):447—450.
3. Holla M. Value of a rigid collar in addition to head blocks: A proof of principle study. J Emerg Med. 2012 Feb;29 (2) 104—7.
4. Chan D, Goldberg R, Tascone A, et al. The effect of spinal immobilization on health volunteers. Ann Emer Med. 1994;23(1):48-51. 5. March J, Ausband S, Brown L. Changes in physical examination caused by the use of spinal immobilization. Prehosp Emerg Care. 2002;6(4):21—24.
6. Hauswald M, Hsu M, Stockoff C. Maximizing comfort and minimizing ischemia: A comparison of four methods of spinal immobilization. Prehosp Emerg Care. 2000;4(3):250—252.
7. Luscombe M, Williams J. Comparison of a long spine board and vacuum mattress for spinal immobilization. Emerg Med J. 2003:20:476—478.
8. Dixon M, O’Halloran J, Cummins N. Research Abstracts for the 2013 National Association of Emergency Medical Services Physicians Assembly. Prehosp Emerg Care. 2013;17(1:)106. Viewed July 26 online at www.naemsp.org/Documents/PEC%20Abstracts.pdf.
9. Engsberg J, Standeven J, Shurtleff T, et al. Cervical Spine Motion During Extrication. J Emer Med. 2013;44(1):122—127.
